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2016 handbook of critical and intensive care medicinethird edition

Joseph Varon

Handbook of
Critical and Intensive
Care Medicine
Third Edition

123


Handbook of Critical
and Intensive
Care Medicine



Handbook of Critical
and Intensive
Care Medicine

Third Edition

Joseph Varon, MD, FACP, FCCP,
FCCM, FRSM

Professor of Acute and Continuing Care, The University
of Texas Health Science Center at Houston
Clinical Professor of Medicine, The University
of Texas Medical Branch at Galveston
Professor of Medicine and Surgery
UAT, UABC, USON, UPAEP, BUAP - Mexico
President Dorrington Medical Associates, PA
Houston, TX, USA
With 25 Illustrations


Joseph Varon MD, FACP, FCCP, FCCM, FRSM
Professor of Acute and Continuing Care
The University of Texas Health
Science Center at Houston
Clinical Professor of Medicine
The University of Texas Medical
Branch at Galveston
Professor of Medicine and Surgery
UAT, UABC, USON, UPAEP, BUAP - Mexico
President Dorrington Medical Associates, PA
Houston, TX, USA

ISBN 978-3-319-31603-1
ISBN 978-3-319-31605-5
DOI 10.1007/978-3-319-31605-5

(eBook)

Library of Congress Control Number: 2016941876
© Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the
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The use of general descriptive names, registered names, trademarks, service marks,
etc. in this publication does not imply, even in the absence of a specific statement,
that such names are exempt from the relevant protective laws and regulations and
therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and
information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or
implied, with respect to the material contained herein or for any errors or omissions
that may have been made.
Printed on acid-free paper
This Springer imprint is published by Springer Nature
The registered company is Springer International Publishing AG Switzerland


This book is again dedicated to my children
Adylle, Jacques, Daryelle, and Michelle for
their understanding as youngsters and adults,
about those countless days, nights, and
weekends, in which I was away from home
caring for those patients who needed me the
most at the time.
Joseph Varon, MD, FACP, FCCP, FCCM, FRSM



Preface
Why write another book on the management of critically ill patients? When I wrote
the first edition of this book, over 20 years ago, I had realized the importance of a
small pocket book that would be useful for those caring for critically ill patients.
Over the past six decades we have seen an enormous growth in the number of intensive care units (ICU) across the world. Indeed, it is estimated that a large proportion
of health-care expenses are devoted to patients in these specialized units. Medical
students, residents, fellows, attending physicians, critical care nurses, pharmacists,
respiratory therapists, and other health-care providers (irrespective of their ultimate
field of practice) will spend several months or years of their professional lives, taking care of critically ill or severely injured patients. These clinicians must have
special training, experience, and competence in managing complex problems in
their patients. Moreover, these clinicians must interpret data obtained by many kinds
of monitoring devices, and they must integrate this information with their knowledge of the pathophysiology of disease. Even more important is the fact that anyone
working in an ICU or with a critically ill patient must approach patients with a
multidisciplinary team. The phrase there is no I in TEAM comes to mind.
This 3rd edition of this book was written for every practitioner engaged in
Critical Care Medicine across the world. I have attempted to present basic and
generally accepted clinical information, my own personal experience in the field,
facts and some important formulas, as well as laboratory values and tables which
we feel will be useful to the practitioner of Critical Care Medicine. The chapters
of this book follow an outline format and are divided by organ-system (i.e.,
neurologic disorders, cardiovascular disorders), as well as special topics (i.e.,
environmental disorders, trauma, toxicology). Every chapter has been updated
and many chapters are completely new.
It is important for the reader of this handbook to understand that Critical Care
Medicine is not a static field and changes occur every day. Therefore, this handbook is not meant to define the standard of care, but rather to be a general guide
to current clinical practice used in Critical Care Medicine. I wrote this book hoping that it will benefit thousands of critically ill patients, but more importantly that
it will aid practicing clinicians to assume a multidisciplinary approach.
Joseph Varon,
MD, FACP, FCCP, FCCM, FRSM



Contents
1

Approach to the Intensive Care Unit (ICU) ..........................................
Welcome to the ICU ..................................................................................
What Is an ICU? ................................................................................
Historical Development of the ICU ..................................................
Economical Impact of the ICU .........................................................
Organization of the ICU ....................................................................
Teamwork...................................................................................................
The Flow Sheet ..........................................................................................
The Critically Ill Patient ............................................................................
System-Oriented Rounds ...........................................................................
Identification......................................................................................
Major Events Over the Last 24 h ......................................................
System Review ..................................................................................
Do Not Resuscitate (DNR) and Ethical Issues ..........................................

1
1
1
1
2
2
2
3
3
4
5
6
6
9

2

The Basics of Critical Care ...................................................................
Cardiac Arrest and Resuscitation ............................................................
The Alveolar Air Equation ......................................................................
Oxygen Transport ....................................................................................
Mechanical Ventilation ............................................................................
Hemodynamics ........................................................................................
The Cardiopulmonary Interaction............................................................
Integrated Cardiopulmonary Management
Principles..................................................................................................

11
11
18
24
29
40
46
48

Cardiovascular Disorders .....................................................................
Ischemic Heart Disease............................................................................
Unstable Angina Pectoris ................................................................
Myocardial Infarction ......................................................................
Cardiac Pacemakers.........................................................................
Congestive Heart Failure .................................................................
Cardiomyopathies ............................................................................
Myocarditis ......................................................................................
Pericarditis .......................................................................................

51
51
51
54
62
62
64
66
66

3


x

4

5

Contents
Valvular Heart Disease ....................................................................
Aortic Dissection .............................................................................
Shock States ....................................................................................
Infective Endocarditis ......................................................................
Dysrhythmias...................................................................................
Hypertensive Crises .........................................................................
Useful Facts and Formulas ..............................................................

68
72
73
75
76
79
80

Endocrinologic Disorders ....................................................................
Adrenal Insufficiency ...............................................................................
Diabetes Insipidus ....................................................................................
Syndrome of Inappropriate
Antidiuretic Hormone Secretion (SIADH) ..............................................
Diabetic Ketoacidosis and Hyperosmolar
Nonketotic Coma .....................................................................................
Tight Glycemic Control in the ICU .......................................................
Myxedema..............................................................................................
Thyrotoxic Crisis ...................................................................................
Sick Euthyroid Syndrome ......................................................................
Hypoglycemia ........................................................................................
Pheochromocytoma................................................................................

89
89
92
95
97
101
101
106
109
110
114

Environmental Disorders ....................................................................
Burns ......................................................................................................
Decompression Illness and Air Embolism ............................................
Electrical Injuries ...................................................................................
Heat Exhaustion and Heatstroke............................................................
Hypothermia ..........................................................................................
Smoke Inhalation and Carbon Monoxide
Poisoning................................................................................................
Scorpion Envenomation .........................................................................
Snakebite ................................................................................................
Spider Bite .............................................................................................
Useful Facts and Formulas ....................................................................

117
117
120
122
125
128

6

Gastrointestinal Disorders ..................................................................
Gastrointestinal Bleeding .......................................................................
Acute Mesenteric Ischemia....................................................................
Fulminant Hepatic Failure and Encephalopathy .......................................
Pancreatitis .............................................................................................
Useful Facts and Formulas ....................................................................

145
145
149
151
154
157

7

Hematologic Disorders ........................................................................
Anemia ...................................................................................................
Leukopenia .............................................................................................
Thrombocytopenia .................................................................................

159
159
161
164

131
133
135
138
140


Contents

xi

Anticoagulation and Fibrinolysis ...........................................................
Blood and Blood Product Transfusion ..................................................
Disseminated Intravascular Coagulation ...............................................
Hemolytic Syndromes............................................................................
Useful Facts and Formulas ....................................................................

166
170
172
174
177

8

Infectious Diseases ...............................................................................
Pneumonia (Nosocomial) ......................................................................
Community-Acquired Pneumonia .........................................................
Severe Adult Respiratory Syndrome (SARS)........................................
Sepsis .....................................................................................................
Toxic Shock Syndrome ..........................................................................
Meningitis ..............................................................................................
Infections in Patients with AIDS ...........................................................
Infections in the Immunocompromised Host ........................................
Antimicrobials........................................................................................
Infectious Diseases: “Pearls” for ICU Care...........................................
Useful Facts and Formulas ....................................................................

181
181
183
185
186
187
188
191
194
197
199
199

9

Neurologic Disorders ...........................................................................
Brain Death ............................................................................................
Coma ......................................................................................................
Intracranial Hypertension ......................................................................
Cerebrovascular Disease ........................................................................
Status Epilepticus ...................................................................................
Neuromuscular Disorders ......................................................................
Delirium in the ICU ...............................................................................
Useful Facts and Formulas ....................................................................

203
203
205
208
210
213
215
216
218

10

Nutrition................................................................................................
Aims of Nutritional Support ..................................................................
Timing of Nutritional Support ...............................................................
Route of Nutritional Support .................................................................
Gastrointestinal Function During Critical Illness ...................................
Nutrient Requirements (Quantity) .........................................................
Role of Specific Nutrients (Quality) ......................................................
Monitoring Responses to Nutritional Support .......................................
Nutrition for Specific Disease Processes ...............................................
Nasoduodenal Feeding Tube Placement ................................................
Recommendations for TPN Use ............................................................
Approach to Enteral Feeding .................................................................
Useful Facts and Formulas ....................................................................

223
223
223
224
226
227
229
232
233
233
234
235
237

11

Critical Care Oncology........................................................................
Central Nervous System ........................................................................
Pulmonary ..............................................................................................

243
243
248


xii

Contents
Cardiovascular .......................................................................................
Gastroenterology ....................................................................................
Renal/Metabolic .....................................................................................
Hematology ............................................................................................
Chemotherapy-Induced Hypersensitivity
Reactions ................................................................................................
Immune Compromise ............................................................................
Useful Facts and Formulas ....................................................................

250
253
254
258

12

Critical Care of the Pregnant Patient ................................................
Pregnancy-Induced Hypertension ..........................................................
Prevention ..............................................................................................
Amniotic Fluid Embolism .....................................................................
Useful Facts and Formulas ....................................................................

263
263
279
279
282

13

Pulmonary Disorders ...........................................................................
Chronic Obstructive Pulmonary Disease (COPD) ...................................
Asthma ...................................................................................................
Pulmonary Embolism ............................................................................
Adult Respiratory Distress Syndrome (ARDS) .....................................
Acute Respiratory Failure ......................................................................
Barotrauma.............................................................................................
Massive Hemoptysis ..............................................................................
Upper Airway Obstruction.....................................................................
Useful Facts and Formulas ....................................................................

285
285
289
292
297
300
303
305
307
307

14

Renal and Fluid–Electrolyte Disorders .............................................
Acid–Base Disturbances ........................................................................
Acute Renal Failure/Acute Kidney Injury .............................................
Electrolyte Abnormalities ......................................................................
Fluid and Electrolyte Therapy ...............................................................
Dialysis ..................................................................................................
Rhabdomyolysis.....................................................................................
Useful Facts and Formulas ....................................................................

317
317
324
328
340
341
342
344

15

Special Techniques ...............................................................................
Airway Management..............................................................................
Cardioversion/Defibrillation ..................................................................
Vascular Access .....................................................................................
Arterial Line ...........................................................................................
Pulmonary Artery Catheterization .........................................................
Tube Thoracostomy ...............................................................................
Intra-aortic Balloon Pump (IABP) ........................................................
Pericardiocentesis ..................................................................................
Therapeutic Hypothermia (TH) .............................................................
Bronchoscopy ........................................................................................

355
355
359
360
365
366
367
369
369
372
373

258
259
260


Contents
16

xiii

Toxicology .............................................................................................
General Management .............................................................................
Acetaminophen ......................................................................................
Alcohol...................................................................................................
Angiotensin-Converting Enzyme
(ACE) Inhibitors .....................................................................................
Beta-Blockers .........................................................................................
Cocaine ..................................................................................................
Cyanide ..................................................................................................
Cyclic Antidepressants ..........................................................................
Digoxin ..................................................................................................
Narcotics ................................................................................................
Phencyclidine .........................................................................................
Phenytoin ...............................................................................................
Salicylates ..............................................................................................
Sedatives/Hypnotics ...............................................................................
Theophylline ..........................................................................................
Crystal Meth ..........................................................................................
Useful Facts and Formulas ....................................................................

375
375
377
379

17

Trauma ..................................................................................................
Multisystem Trauma ..............................................................................
Head Trauma ..........................................................................................
Crush Injury ...........................................................................................
Chest Trauma .........................................................................................
Abdominal Trauma ................................................................................
Multiple Fractures ..................................................................................
Spinal Cord Injury .................................................................................
Useful Facts and Formulas ....................................................................

397
397
401
404
405
406
408
410
412

18

Allergic and Immunologic Emergencies ............................................
Anaphylaxis ...........................................................................................
Stevens–Johnson Syndrome
(Erythema Multiforme) ..........................................................................
Angioneurotic Laryngeal Edema ...........................................................

417
417

19

381
381
382
383
384
385
387
388
388
389
391
392
393
393

420
421

Pharmacologic Agents Commonly Used
in the ICU .............................................................................................

423

Common Laboratory Values in the ICU ...........................................

435

Index ...............................................................................................................

443

20



About the Author
Joseph Varon, MD, FACP, FCCP, FCCM, FRSM, Dr. Varon is the Chief of Critical
Care Services at Foundation Surgical Hospital of Houston and Past Chief of Staff
at University General Hospital. He is a Professor of Acute and Continuing Care at
the University of Texas Health Science Center in Houston, Texas, and Clinical
Professor of Medicine at the University of Texas Medical Branch in Galveston. He
is also Professor of medicine, surgery, and emergency medicine at several universities in Mexico, the Middle East, and Europe.
After completing medical training at the UNAM Medical School in Mexico
City, Mexico, Dr. Varon served as internship in internal medicine at Providence
Hospital/George Washington University, Washington, D.C. A subsequent residency in internal medicine was completed at Stanford University School of
Medicine in Stanford, California. Dr. Varon also served fellowships in Critical
Care Medicine and pulmonary diseases at Baylor College of Medicine in Houston.
An avid researcher, Dr. Varon has contributed more than 675 peer-reviewed
journal articles, 10 full textbooks, and 10 dozen book chapters to the medical literature. He is also a Reviewer for multiple journals and currently serves as Editorin-Chief for Critical Care and Shock and Current Respiratory Medicine Reviews.
Dr. Varon has won many prestigious awards and is considered among one of the
top physicians in the United States.
Dr. Varon is also known for his groundbreaking contributions to Critical Care
Medicine in the fields of cardiopulmonary resuscitation and therapeutic hypothermia. He has developed and studied technology for selective brain cooling. He is
also a well-known expert in the area of hypertensive crises management. With Dr.
Carlos Ayus, he co-described the hyponatremia associated to extreme exercise
syndrome also known as the “Varon-Ayus syndrome.”
Dr. Varon has lectured in over 55 different countries around the globe. Along
with Professor Luc Montagnier (Nobel Prize Winner for Medicine in 2008), Dr.
Varon created the Medical Prevention and Research Institute in Houston, Texas,
where they conduct work on basic sciences projects. Dr. Varon has appeared in
National and International television and radio shows with his techniques and care
of patients. He is well known for his academic and clinical work in the management
of acute hypertension and has published extensively on this subject. In addition, Dr.
Varon has worked on studies related to ethical issues in acute care medicine and has
several peer-reviewed publications on this controversial subject.


1
Approach to the
Intensive Care Unit (ICU)
I. WELCOME TO THE ICU
What Is an ICU?
An intensive care unit (ICU) is an area of a hospital that provides aggressive therapy,
using state-of-the-art technology and both invasive and noninvasive monitoring for
critically ill and high-risk patients. In these units the patient’s physiological variables are
reported to the practitioner on a continuous basis, so that titrated care can be provided.
As a medical student, resident physician, attending physician, or other healthcare
provider, one is likely to spend several hundreds of hours in these units caring for
very sick patients. Knowing the function and organization of these specialized areas
will help the practitioner in understanding critical care.

Historical Development of the ICU
The origin of the ICU remains controversial. In 1863, Florence Nightingale wrote, “In
small country hospitals there are areas that have a recess or small room leading from
the operating theater in which the patients remain until they have recovered, or at least
recover from the immediate effects of the operation.” This is probably the earliest
description of what would become the ICU. Recovery rooms were developed at the
Johns Hopkins Hospital in the 1920s. In Germany in the 1930s, the first well-organized
postoperative ICU was developed. In the United States, more specialized postoperative
recovery rooms were implemented in the 1940s at the Mayo Clinic. By the late 1950s,
the first shock unit was established in Los Angeles. The initial surveillance unit for
patients after acute myocardial infarction was started in Kansas City in 1962.
© Springer International Publishing Switzerland 2016
J. Varon, Handbook of Critical and Intensive Care Medicine,
DOI 10.1007/978-3-319-31605-5_1


2

1. Approach to the Intensive Care Unit (ICU)

Economical Impact of the ICU
Since their initial development, there has been a rapid and remarkable growth of ICU
beds in the United States. There are presently more than 60,000 ICU beds in the
United States, and critical care consumes more than 2.5 % of the gross national
product.

Organization of the ICU
ICUs in the United States may be open or closed. Open ICUs may be utilized by any
attending physician with admitting privileges in that institution, and many subspecialists may manage the patient at the same time. These physicians do not need to be
specifically trained in critical care medicine. A different system is provided in closed
ICUs, in which the management of the patient on admission to the unit is provided
by an ICU team and orchestrated by physicians with specialized training in critical
care medicine. Although consultants may be involved in the patient’s care, all orders
are written by the ICU team, and all decisions are approved by this team.
ICUs may also be organized by the type of patients whom they are intended to
treat. In some studies, these “closed” units have shown shorter length of stay for the
ICU patients due to the standardization of care.
ICUs can also be divided on the basis of the patients they have. Examples include
the neurosurgical ICU (NICU), pediatric ICU (PICU), cardiovascular surgery ICU
(CVICU), surgical ICU (SICU), medical ICU (MICU), and coronary care unit
(CCU).
Most ICUs in the United States have a medical director who, with varying
degrees of authority, is responsible for bed allocation, policy making, and quality
assurance and who may be, particularly in closed ICUs, the primary attending physician for patients admitted to that unit.

II. TEAMWORK
Care of the critically ill patient has evolved into a discipline that requires specialized
training and skills. The physician in the ICU depends on nursing for accurate charting and assessment of the patients during the times when he or she is not at the
bedside and for the provision of the full spectrum of nursing care, including psychological and social support and the administration of ordered therapies.
Complex mechanical ventilation devices need appropriate monitoring and
adjustment. This expertise and other functions are provided by a professional team
of respiratory therapy practitioners. The wide spectrum of the pharmacopeia used in
the ICU is greatly enhanced by the assistance of our colleagues in pharmacy. Many
institutions find it useful to have pharmacists with advanced training participate in
rounding to help practitioners in the appropriate pharmacologic management of the
critically ill. Additionally, technicians with experience in monitoring equipment may


IV. The Critically Ill Patient

3

help in obtaining physiologic data and maintaining the associated equipment.
Without these additional healthcare professionals, optimal ICU management would
not be possible.
As many ICU patients remain in these units for prolonged periods of time, additional healthcare providers, such as the nutritional support team and physical/occupational therapy, remain important component of the management of these patients.

III. THE FLOW SHEET
ICU patients, by virtue of their critical illnesses, present with complex pathophysiology and symptomatology. In many cases, these patients are endotracheally intubated,
with mental status depression, and cannot provide historical information. The physical examination and monitoring of physiology and laboratory data must provide the
information on which to base a diagnosis and initiate appropriate treatment in these
cases.
The flow sheet is the repository of information necessary for the recognition
and management of severe physiological derangements in critically ill patients.
A well-organized flow sheet provides around-the-clock information regarding
the different organ systems rather than just vital signs alone. In many institutions, these flow sheets are computerized, potentially improving accessibility
and allowing real-time data. These devices are complex and in many instances
expensive.
Major categories appropriate for an ICU flow sheet include:
• Vital signs
• Neurological status
• Hemodynamic parameters
• Ventilator settings
• Respiratory parameters
• Inputs and outputs
• Laboratory data
• Medications

IV. THE CRITICALLY ILL PATIENT
In general, ICU patients not only are very ill but also may have disease processes
that involve a number of different organ systems. Therefore, the approach to the
critically ill patient needs to be systematic and complete (see below).
Several issues need to be considered in the initial approach to the critically ill
patient. The initial evaluation consists of assessment of the ABC (airway, breathing,
circulation), with simultaneous interventions performed as needed. An organized
and efficient history and physical examination should then be conducted for all
patients entering the ICU, and a series of priorities for therapeutic interventions
should be established.


4

1. Approach to the Intensive Care Unit (ICU)

V. SYSTEM-ORIENTED ROUNDS
In the ICU accurate transmission of clinical information is required. It is important
to be compulsive and follow every single detail. The mode of presentation during
ICU rounds may vary based on institutional tradition. Nevertheless, because of multiple medical problems, systematic gathering and presentation of data are needed for
proper management of these patients. We prefer presenting and writing notes in a
“head-to-toe” format (see Table 1.1).
Table 1.1 Minimum amount of information necessary for presentation during
rounds (see text for details)
ICU survival guide for presentation during rounds
1. Identification/problem list
2. Major events during the last 24 h
3. Neurological:
Mental status, complaints, detailed neurological exam (if pertinent)
4. Cardiovascular:
Record symptoms and physical findings, BP, pulse variability over the past
24 h, ECG, and echocardiogram results
If CVP line and/or Swan-Ganz catheter is in place, check CVP and
hemodynamics yourself
5. Respiratory:
Ventilator settings, latest ABGs, symptoms and physical findings, CXR (daily if
the patient is intubated). Other calculations (e.g., compliance, minute volume,
etc.)
6. Renal/metabolic:
Urine output (per hour and during the last 24 h), inputs/outputs with balance
(daily, weekly), weight, electrolytes, and, if done, creatinine clearance. Acid–
base balance interpretation
7. Gastrointestinal:
Abdominal exam, oral intake, coffee grounds, diarrhea. Abdominal X-rays, liver
function tests, amylase, etc.
8. Infectious diseases:
Temperature curve, WBC, cultures, current antibiotics (number of days on
each drug), and antibiotic levels
9. Hematology:
CBC, PT, PTT, TT, BT, DIC screen (if pertinent), peripheral smear.
Medications altering bleeding
10. Nutrition:
TPN, enteral feedings, rate, caloric intake, and grams of protein
(continued)


V. System-Oriented Rounds

5

Table 1.1 (continued)
ICU survival guide for presentation during rounds
11. Endocrine:
Do you need to check TFTs or cortisol? Give total insulin needs per hour and 24 h
12. Psychosocial:
Is the patient depressed or suicidal? Is the family aware of his or her present
condition?
13. Others:
Check the endotracheal tube position (from lips or nostrils in centimeters) and
check CXR position. Check all lines and transducers. Note position of the
catheter and skin insertion sites. Skin examination for pressure ulcers, rash,
and any other changes should be documented
All medications and drips must be known. All drips must be renewed before or
during rounds
ABG arterial blood gas, BP blood pressure, BT bleeding time, CBC complete blood count, CXR chest
X-ray, CVP central venous pressure, DIC disseminated intravascular coagulation, ECG electrocardiogram, PT prothrombin time, PTT partial thromboplastin time, TFT thyroid function tests, TPN total
parenteral nutrition, TT thrombin time, WBC white blood cell count

The ICU progress note is system oriented, which differs from the problemoriented approach commonly utilized on the general medicine–surgery wards. The
assessment and plan are formulated for each of the different organ systems as aids
to organization, but like in the non-ICU chart, each progress note should contain a
“problem list” that is addressed daily. This problem list allows the healthcare provider to keep track of multiple problems simultaneously and enables a physician
unfamiliar with a given case to efficiently understand its complexities if the need
arises.
The art of presenting cases during rounds is perfected at the bedside over many
years, but the following abbreviated guide may get the new member of the ICU team
off to a good start. A “how-to” for examining an ICU patient and a stylized ICU
progress note guide are also presented. Remember that for each system reviewed, a
full review of data, assessment, and management plan should be provided. Using this
simple technique avoids important data to be skipped or forgotten.
When you arrive in the ICU in the morning:
1. Ask the previous night’s physicians and nurses about your patients.
2. Go to the patient’s room. Review the flow sheet. Then proceed by examining and
reviewing each organ system as follows:

Identification


Provide name, age, major diagnoses, day of entry to the hospital, and day of
admission to the ICU.


6

1. Approach to the Intensive Care Unit (ICU)

Major Events Over the Last 24 h


Mention (or list in the progress note) any medical event or diagnostic endeavor
that was significant. For example, major thoracic surgery or cardiopulmonary
arrest, computed tomography (CT) scan of the head, reintubation, or changes in
mechanical ventilation.

System Review
Neurologic
• Mental status: Is the patient awake? If so, can you perform a mental status exami•




nation? If the patient is comatose, is he or she spontaneously breathing?
What is the Glasgow Coma Scale score? Does the patient have a cough or gag
reflex?
If the patient is sedated, what is the Ramsay score, or what is the score or any other
scales (i.e., RASS) used at the institution for patients who are sedated?
If pertinent (in patients with major neurological abnormalities or whose major
disease process involves the central nervous system), a detailed neurological exam
should be performed.
What are the results of any neurological evaluation in the past 24 h, such as a
lumbar puncture or CT scan?

Cardiovascular
• Symptoms and physical findings: It is important to specifically inquire for symp•






toms of dyspnea, chest pain, or discomfort, among others. The physical examination should be focused on the cardiac rhythm, presence of congestive heart failure,
pulmonary hypertension, pericardial effusion, and valvulopathies.
Electrocardiogram (ECG): We recommend that a diagnostic ECG be considered
in every ICU patient on a frequent basis. Many ICU patients cannot communicate
chest pain or other cardiac symptomatology, so an ECG may be the only piece of
information pointing toward cardiac pathology.
If the patient has a central venous pressure (CVP) line and/or a pulmonary artery
(Swan-Ganz) catheter in place, check the CVP and hemodynamics yourself.
Hemodynamic calculations of oxygen consumption and delivery should be noted
if the patient has a pulmonary artery catheter or an oximetric intravascular device.
A detailed list of hemodynamic parameters useful in the management of critically
ill patients can be found in Chaps. 3, “Cardiovascular Disorders,” and 13,
“Pulmonary Disorders.”
Note the blood pressure (BP) and pulse variability over the past 24 h. Calculate
the mean arterial pressure (MAP) changes over the time period.
If the patient had an echocardiogram, review the findings in detail.
If the patient is receiving assisted mechanical cardiac support (i.e., intra-aortic
balloon pump) or has a temporary pacemaker, the settings need to be recorded and
compared to prior days.


V. System-Oriented Rounds

7

Respiratory
• If the patient is on mechanical ventilation, the current ventilator settings need to





be charted, including the ventilatory mode, tidal volume, preset respiratory rate
and patient’s own respiratory rate, amount of oxygen being provided (FiO2), and
whether or not the patient is receiving positive end-expiratory pressure (PEEP)
and/or pressure support (PS) and their levels. When pertinent, peak flow settings
and inspiration–expiration (I:E) ratio should be noted. Mechanically ventilated
patients should have a daily measurement of the static and dynamic compliance,
minute volume, and other parameters (see Chaps. 2, “The Basics of Critical Care”
and 13, “Pulmonary Disorders”). If weaning parameters were performed, they
need to be addressed.
The most recent arterial blood gases (ABGs) should be compared with previous
measurements. Calculation of the alveolar–arterial oxygen gradient should be
performed in all ABGs.
Symptoms and physical findings should be noted, and if pertinent, sputum characteristics should be mentioned.
Generally, a portable chest X-ray is obtained in all intubated patients daily.
Attention is paid to CVP lines, endotracheal tubes, chest tubes, pericardiocentesis
catheters, opacities in the lung fields (infiltrates), pneumothoraces, pneumomediastinum, and subcutaneous air.

Renal/Metabolic
• Urine output is quantified per hour and during the past 24 h. In patients requiring





intensive care for more than 2 days, it is important to keep track of their inputs,
outputs, and overall daily and weekly fluid balance.
Daily weights.
If the patient underwent hemodialysis or is on peritoneal dialysis, it is important
to include it on the daily note.
Electrolytes are noted including magnesium, phosphorus, and calcium (ionized),
and, if done, creatinine clearance, urine electrolytes, etc. Any changes in these
values need special consideration.
The ABGs are used for acid–base balance interpretation. The formulas most commonly used for these calculations are depicted in Chap. 14, “Renal and FluidElectrolyte Disorders.”

Gastrointestinal
• Abdominal examination:





A detailed abdominal examination may uncover new
pathology or allow one to assess changes in recognized problems.
If the patient is awake and alert, mention his or her oral intake (e.g., determine
whether clear liquids are well tolerated).
The characteristics of the gastric contents or stool (e.g., coffee grounds, diarrhea,
etc.) should also be mentioned and recorded.
Abdominal X-rays, if pertinent, are reviewed with special attention to the duration
of feeding tubes, free air under the diaphragm, and bowel gas pattern.
Liver function tests (transaminases, albumin, coagulation measurements, etc.) and
pancreatic enzymes (amylase, lipase, etc.) are mentioned and recorded when pertinent, as well as their change since previous measurements.


8

1. Approach to the Intensive Care Unit (ICU)

Infectious Diseases
• Temperature curve: Changes in temperature (e.g., “fever spike” or hypothermia)






should be noted as well as the interventions performed to control the temperature.
Note fever character, maximum temperature in 24 h (T-max), and response to
antipyretics.
The total white blood cell count (WBC) is recorded, when pertinent, with special
attention to changes in the differential.
Cultures: Culture (blood, sputum, urine, etc.) results should be checked daily with
the microbiology laboratory and recorded. Those positive cultures, when mentioned, should include the antibiotic sensitivity profile, when available.
Current antibiotics: Current dosages and routes of administration as well as the
number of days on each drug should be reported. If an adverse reaction occurred
related to the administration of antibiotics, it should be reported.
Antibiotic levels are drawn for many antibiotics with known pharmacokinetics to
adjust their dosage (e.g., peak and trough levels for vancomycin).
If the patient is receiving a new drug, either investigational or FDA approved, side
effects and/or the observed salutary effects are reported.

Hematology
• Complete blood cell count (CBC): When presenting the results, it is important to




be aware of the characteristics of the peripheral blood smear.
Coagulation parameters: The prothrombin time (PT), partial thromboplastin time
(PTT), thrombin time (TT), bleeding time (BT), and disseminated intravascular
coagulation (DIC) screen (e.g., fibrinogen, fibrin split products, d-dimer, platelet
count) should be addressed when pertinent.
If the patient has received blood products or has undergone plasma exchange, this
should be noted.
In this context special attention is paid to all medications that alter bleeding, both
directly (e.g., heparin, desmopressin acetate) and indirectly (e.g., ticarcillininduced thrombocytopathy, ranitidine-induced thrombocytopenia).

Nutrition
• Total parenteral



nutrition (TPN): You need to state what kind of formula the
patient is receiving, the total caloric intake provided by TPN with the percentage
of fat and carbohydrates given. The total amount of protein is mentioned with an
assessment of the anabolic or catabolic state (see Chap. 10, “Nutrition”).
Enteral feedings: These are reported similar to TPN, with mention of any gastrointestinal intolerance (e.g., diarrhea).
For both of the above, the nutritional needs of the patient and what percentage of
these needs is actually being provided must be reported.

Endocrine
• Special attention is paid to pancreatic, adrenal, and thyroid function. If needed, a

cortisol level or thyroid function tests are performed. In most situations these determinations are not appropriate in the ICU except under special circumstances (e.g.,


VI. Do Not Resuscitate (DNR) and Ethical Issues





9

hypotension refractory to volume resuscitation in a patient with disseminated tuberculosis, Addisonian crisis), and the results are usually not available immediately.
Glucose values: The data are clear that good glycemic control helps patients in the
ICU. Therefore, you must include the glycemic variation that the patient has over
the past 24 h.
Insulin: The total insulin needs per hour and per 24 h as well as the blood sugar values
should be reported. The type of insulin preparation being used should be specified.
In patients with hyperosmolal states and diabetic ketoacidosis, it is necessary to
determine calculated and measured serum osmolality as well as ketones. The
values for these are charted and compared with previous results.

Psychosocial
• Patients in the ICU


tend to be confused and in many instances disoriented.
Although these symptoms and signs are reviewed as part of the neurological examination, it is important to consider other diagnoses (e.g., depression, psychosis).
For drug overdoses and patients with depression, specific questions need to be
asked regarding the potential of new suicidal and homicidal ideations.

Others
Other parameters also must be checked daily before the morning (or evening)
rounds:
• Check the endotracheal tube size and position (from the lips or nostrils in centimeters), and check its position on chest X-ray, as mentioned above.
• If the patient has a nasotracheal or orotracheal tube, a detailed ear, nose, and throat
examination should be performed (because patients with nasotracheal tubes may
develop severe sinusitis).
• Check all lines with their corresponding equipment (e.g., transducers must be at an
adequate level). Note the position of the catheter(s) both on physical examination and
on X-ray, as well as the appearance of the skin insertion site(s) (e.g., infection).
• All medications and continuous infusions and their proper concentrations and
infusion rates must be known and recorded.
• At the time of “pre-rounding,” all infusions must be renewed. TPN orders need to
be written early, with changes based on the most recent laboratory findings.
• At the end of rounds every morning, it is important to keep a list of the things that
need to be done that day, for example, changes in central venous lines or arterial
lines, performing a lumbar puncture, etc.

VI. DO NOT RESUSCITATE (DNR) AND ETHICAL
ISSUES
Ethical issues arise every day in the ICU. For example, should a particular patient be
kept on mechanical ventilation when he has an underlying malignancy? Should the
patient with acquired immune deficiency syndrome (AIDS) receive cardiopulmonary


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